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Aligning risk adjustment and quality management

Many health plans maintain separate risk adjustment and quality management programs, with purposefully siloed objectives and metrics. But aligning the two enables true transparency from data to analytics, and provides numerous benefits:

Revenue growth

Improved outcomes

Reduced medical spend

Managing at-risk populations requires health plans to have the appropriate controls and processes in place that accurately capture and manage the relative health of these members. For government-sponsored plans particularly, risk adjustment and quality management both may use retrospective chart review, prospective physician engagement and prospective member engagement to achieve their individual goals.

Transparency, not redundancy, is the key to maintaining the goals of risk adjustment and quality management programs. Review best practices here.

Considerations for vendor management
The more vendors you have between you and your constituents, the more touch points there are to potentially expose you to variability in reporting and accuracy. While it may not be possible to consolidate to just one vendor, it’s important to achieve visibility between vendors. Consider having one trusted vendor partner oversee the others to deliver a disciplined line of sight and control. It’s also essential that you monitor touch points to achieve complete transparency across your programs.

About the Author:Sam Diederich is a Director of Risk and Quality Strategy for Optum and has been responsible for the quality programs offered to payers for the past three years. He has earned degrees in finance and economics from the University of St. Thomas in St. Paul, MN. Within his Risk and Quality Strategy role, Sam is focusing time on risk programs for both Medicare and commercial payers, as well as assisting payers with risk and quality program and strategy alignment.